Pigmented Bowen's disease (squamous cell carcinoma in situ): a mimic of malignant melanoma.

BACKGROUND: Darkly pigmented individuals may manifest unusual or uncharacteristic presentations of various skin conditions, including heavy pigmentation of cutaneous tumors. OBJECTIVE: To increase the awareness of an unusual presentation of Bowen's disease in a darkly pigmented individual. METHODS: We report the case of a 52 year old black woman that presented with a lesion clinically consistent with malignant melanoma. However, histopathologic examination revealed pigmented Bowen's disease. RESULTS: A biopsy is almost always indicated to confirm the diagnosis of lesions in darkly pigmented individuals. CONCLUSION: This case is presented to reinforce the idea that pigmented Bowen's disease should be considered in the differential diagnosis of malignant melanoma.

Cutaneous malignant melanoma.

Melanoma is the deadliest form of skin cancer; 47,700 persons were expected to be diagnosed and 9,600 were expected to die from melanoma in 2000 (American Cancer Society, 2000). It is important for dermatology nurses to understand the epidemiology, risk factors, clinical presentation, diagnosis, treatment, prognosis, and prevention of cutaneous malignant melanoma.

High levels of expression of p27KIP1 and cyclin E in invasive primary malignant melanomas.

Cancer cells have abnormal cell cycle regulation which favors accelerated proliferation, chromosomal instability, and resistance to the senescence response. Although the p16INK4a locus is the most prominent susceptibility locus for familial melanomas, the low frequency of p16 mutations in sporadic melanomas suggests additional alterations in other cell cycle regulatory genes. Here we used primary melanoma tumors to reveal early cell cycle alterations that could be masked in advanced metastatic lesions due to their inherently high genetic instability. Unexpectedly, the cyclin-dependent kinase inhibitors p27KIP1 and/or p21Waf-1/SDI-1 were found to be expressed in 13 of 18 (72%) of the primary melanomas with a Breslow thickness greater than 0.076 mm. In general, p27 and/or p21 staining in the primary tumors correlated with low Ki-67 index. Importantly, most of the p21- and p27-positive tumors expressed high levels of cyclin D1 and cyclin E. In proliferating cells p27 is predominantly associated with cyclin D-CDK4 complexes, but does not inhibit the kinase activity, whereas in quiescent cells p27 is found associated with inactive CDK2 complexes. p27 was also expressed at high levels in proliferating primary melanomas in culture, and found to be associated with active cyclin E-CDK2 complexes containing high levels of cyclin E. It is thus likely that accumulation of cyclin E overcomes the potent inhibitory activity of p27 and p21 in CDK2 complexes. Of the primary melanomas with no indication of invasiveness, only three of 15 (20%) were positive for p27 and/or p21. We propose that high levels of p27 and p21 may confer upon melanoma tumors their characteristic resistance to conventional therapies. In turn, high levels of cyclins E and D1 may contribute to unlimited proliferation in primary melanomas that express the tumor suppressor p16INK4. J Invest Dermatol 113:1039-1046 1999

Multiple primary melanoma.

BACKGROUND: Incidence rates of cutaneous malignant melanoma (CMM) have been increasing for decades among Caucasian populations worldwide. Multiple factors identify persons at increased risk of CMM, including those with a family history of melanoma and those with atypical moles. Approximately 6-12% of melanomas are familial and approximately 12% of patients with familial melanoma have multiple primary melanomas. OBJECTIVE: To report a case of a patient with atypical moles and with 17 multiple primary melanomas. To review the literature on multiple primary melanomas as well as to review the genetics and treatment of melanoma. CONCLUSION: Patients with numerous atypical moles and a family or personal history of melanoma are at greatest risk for developing CMM. Patients from this population tend to develop CMM approximately 10 years earlier than the general population and have an increased risk for developing multiple primary melanomas. Since genetic tests capable of detecting individuals with an inherited susceptibility to CMM are not available, it is important to identify those patients with an increased risk and monitor them closely with regular total-body examinations.

The antifungal agent butenafine manifests anti-inflammatory activity in vivo.

BACKGROUND: Dermatophyte infections are often accompanied by a striking inflammatory reaction, alleviation of which has often been achieved by the concomitant but controversial use of topical steroidal agents. Recent investigations have suggested the presence of inherent anti-inflammatory properties associated with certain antifungal agents, particularly those within the allylamine class. Butenafine, the first and only approved representative of the benzylamine antifungals, possesses a chemical structure and antifungal activity similar to the allylamines. Although several studies have demonstrated excellent antimycotic efficacy, none has addressed anti-inflammatory properties associated with butenafine. OBJECTIVE: This study was designed to determine whether butenafine, a benzylamine antifungal, expresses anti-inflammatory activity in vivo. METHODS: A randomized single-blinded control investigation comparing the attenuation of UVB irradiation-induced erythema by butenafine, its proprietary base cream, and no application (negative control) was performed in humans. RESULTS: Butenafine demonstrated a significant and marked decrease in UVB-induced erythema as compared with both the base cream and the unaltered control. CONCLUSION: The benzylamine antifungal agent butenafine demonstrates inherent anti-inflammatory properties, in vivo, as demonstrated by reduced cutaneous erythema response after UVB irradiation.

Exfoliative dermatitis.

Exfoliative dermatitis, also known as erythroderma, is an uncommon but serious skin disorder that family physicians must be able to recognize and treat appropriately. Although the etiology is often unknown, exfoliative dermatitis may be the result of a drug reaction or an underlying malignancy. The approach to treatment should include discontinuation of any potentially causative medications and a search for any underlying malignancy. One of the most common malignancies associated with exfoliative dermatitis is cutaneous T-cell lymphoma, which may not manifest for months or even years after the onset of the skin condition. Hospitalization is usually necessary for initial evaluation and treatment. In the hospital, special attention must be given to maintaining temperature control, replacing lost fluids and electrolytes, and preventing and treating infection. The long-term prognosis is good in patients with drug-induced disease, although the course tends to be remitting and relapsing in idiopathic cases. The prognosis of cases associated with malignancy typically depends on the outcome of the underlying malignancy.

Hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a recurrent, suppurative disease manifested by abscesses, fistulas, and scarring. METHODS: We reviewed the literature to identify reliable information regarding epidemiology, pathogenesis, clinical manifestations, evaluation and differential diagnosis, treatment, complications, and prognosis. RESULTS: Hidradenitis suppurativa usually affects young women, with a prevalence of 0.3% to 4% in industrialized countries. Once considered to be "apocrine acne," HS is actually a defect of terminal follicular epithelium. Obesity, chemical irritants, or hyperandrogenism are not consistently associated; bacterial involvement is secondary. Hidradenitis suppurativa should be suspected in young adults with recurrent, deep furuncular lesions in flexural sites, especially when such lesions respond poorly to antibiotic therapy. Clindamycin and isotretinoin may be useful, though wide excision with healing by granulation is considered most efficacious. Anemia, arthropathy, and squamous cell carcinoma are potential complications. CONCLUSIONS: Since spontaneous resolution is rare and progressive disability the rule, early definitive surgical treatment of HS is advisable.

Desmoplastic malignant melanoma presenting as an erythematous nodule tumor.

Desmoplastic malignant melanoma is an uncommon neoplasm that presents both as a clinical and diagnostic challenge. Prognosis is frequently adversely affected by misdiagnosis and delayed diagnosis of this tumor, which is often amelanotic. We report a case of an amelanotic desmoplastic malignant melanoma that presented as an erythematous nodular tumor.

Squamous cell carcinoma in a patient with chronic lymphocytic leukemia. An intraoperative diagnostic challenge for the Mohs surgeon.

BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most common form of chronic leukemia in the US. CLL patients have an increased risk of developing other malignant neoplasms, especially skin cancer. Lymphoma-associated squamous cell carcinomas (SCCs) tend to behave more aggressively and therefore are often treated with Mohs micrographic surgery (MMS). OBJECTIVE: To elucidate the potential difficulty of distinguishing perineural infiltrates as leukemic infiltrates versus inflammatory infiltrates associated with SCC on frozen tissue sections during MMS. METHODS: This is a case report illustrating a patient with CLL who develops a SCC on the posterior ear. MMS was employed to treat the patient. Special immunohistochemical stains were performed to help distinguish the type of perineural infiltrate present. RESULTS: The perineural infiltrate was shown by immunohistochemistry to be leukemic in origin. Special stains for keratin revealed no residual SCC hidden in the infiltrate. CONCLUSION: CLL is a malignancy that primarily effects the elderly population and markedly increases their risk of developing skin cancers, especially SCC. An intense infiltrate may be present surrounding the tumor. This case report demonstrates one of the potential challenges the Mohs surgeon may face in interpreting histologic frozen section. Immunohistochemistry may be helpful in providing a more definitive answer to this problem.

Anti-inflammatory activity of antifungal preparations.

BACKGROUND: Although steroid/antifungal combination medications are used extensively, they are associated with potential disadvantages. Antifungal preparations possessing inherent anti-inflammatory activity, leading to rapid symptomatic relief while providing mycologic cure, would be very useful. OBJECTIVE: Our purpose was to investigate the anti-inflammatory activity of proprietary antifungal preparations in an in vivo, human experimental model. METHODS: Using a double-blind, controlled protocol, we assessed the comparative ability of antifungal preparations to suppress the expected delayed erythema response following in vivo human exposure to ultraviolet B (UVB) irradiation generated by a solar stimulator. RESULTS: Currently available allylamine preparations and ciclopirox olamine proved to be the most anti-inflammatory, while ketoconazole was intermediate in anti-inflammatory activity under these experimental conditions. These agents were superior to oxiconazole, econazole, and 2.5% hydrocortisone. CONCLUSIONS: Some antifungal preparations possess inherent anti-inflammatory activity, although the exact mechanism remains uncertain.

Correlation of histologic subtypes of primary basal cell carcinoma and number of Mohs stages required to achieve a tumor-free plane.

BACKGROUND: Certain histologic subtypes of basal cell carcinoma (BCC) behave more aggressively and require more aggressive treatment. OBJECTIVE: The aim of this study was to see whether certain subtypes of BCC require more Mohs stages to achieve tumor-free margins. METHODS: A retrospective study of 342 primary BCCs treated with Mohs micrographic surgery (MMS) was performed identifying the histologic subtype of BCC present and the number of stages required to clear the tumor. RESULTS: The aggressive subtypes (infiltrative, morpheaform, micronodular, and mixed) were most frequently found when high numbers of Mohs stages were required for cure. CONCLUSION: The more aggressive subtypes of BCC require more MMS stages to achieve tumor-free margins, which is consistent with the concept that these subtypes usually require more aggressive treatment from the start.